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Insider Arthritis Tips Newsletter May 2010
May 17, 2010
"If all misfortunes were laid in one common heap whence everyone must take an equal portion, most people would be contented to take their own and depart."
A 52 year old man presented to the office for evaluation of possible gout. He had had an executive physical examination performed one year prior and had an elevated serum uric acid of 10.5 mg/dL. One month prior to being seen, he had noticed pain and swelling in the left foot. A diagnosis of gout was made by his primary care physician. The patient received two non-steroidal anti-inflammatory drugs which didnít help but was then placed on a tapering oral prednisone burst which he was still taking at the time of the initial visit. There was no family history of gout nor were there any diet or alcohol triggers. There was no history of lead exposure.
The clinical examination was remarkable for 1+ swelling involving the left first metatarsophalangeal joint (great toe).
Because the patient was traveling to Italy, he was left on the prednisone and advised to taper it slowly and make an appointment if he flared again. A 24 hour urine collection for uric acid was 589.3 mg/24 hours and his creatinine clearance ( test of kidney function) was normal.
Ten days later, the patient presented with an acute flare of pain and swelling in the first metatarsophalangeal joint. An ultrasound guided aspiration of the joint yielded 0.5 ml of fluid. The joint was injected with 0.25 ml of Depomedrol and 0.25 ml of 1 per cent lidocaine. Monosodium urate crystals were identified in the aspirate using polarized microscopy.
The patient was started on colchicine 0.6 mg twice a day and probenecid twice a day. He was also given a prescription of meloxicam to take on as needed basis.
Note: This patient, because he was active, relatively young, with normal kidney function, and was an undersecretor of urinary uric acid (not putting out a lot of uric acid in the urineÖ the normal way most uric acid is disposed of by the body) was an ideal candidate for a uricosuric drug program. Uricosuric drugs make the patient urinate out more uric acid.
Along with initiation of uric acid lowering therapy he was also placed on prophylactic colchicine which is generally continued for six months when starting uric acid lowering therapy. Colchicine is used to prevent flares of gout that may occur with the lowering of uric acid by medication. Why flares occur during early gout treatment is still not completely known. A new form of colchicines (Colchrys) may be safer than generic colchicine.
This patient could also have been treated with either allopurinol (Zyloprim) or febuxostat (Uloric). These drugs reduce the production of uric acid in the body. They do have more potential side effects than probenicid does. Therefore, the safest choice in this case was probenicid.
Diet also plays a role in gout but itís relatively minor compared with drug therapy. Drug therapy is generally not instituted unless a patient has frequent attacks of gout or has tophaceous gout.
Tophi are collections of uric acid that form around joints. They are a cause of finger lumps and bumps.
The decision to start therapy was made after discussion with the patient. Since he had had two severe attacks within the span of ten days despite a steroid burst, it was felt by both the patient and me that chronic medication therapy was the best option.
There are two new medicines in the pipeline. The first is a drug made by Biocryst that has an immune effect on lymphocytes and reduces uric acid production. Another drug made by Ardea is a drug that increases the excretion of uric acid by the kidneys.
Wei's World May 2010
Last May, I wrote about my mom. She died almost 22 years ago. This time around, Iím going to write about Marcia Hearst, my mother-in-law. She doesnít even know Iím writing about her but she is an amazing lady.
First of all, she raised three daughters. Anybody whoís raised three girls knows what a headache that can be. And she did it while staying relatively sane.
She is 90 now but has the spirit and spunk of someone half her age. She knits up a storm and helps one of my wifeís sisters in her business selling stuffed animals. She knits outfits for these furry friends that are clever and unique. And growing up in Boston, sheís made sure most of her outfits have a Boston Red Sox theme.
And she does all this despite having pretty bad arthritic hands. She is also a wonderful cook. When weíve visited her and Martin, her husband and my father-in-law, she has made some memorable meals. When the kids were little we would try to visit during the Jewish holidays and she would always have a great meal ready for us. In fact, her recipe for turkey stuffing for Thanksgiving is one that my wife, Judy, always makes. So the tradition continues.
In many ways she reminds me of my mom. Hereís what they have in common: both short, both very motherly, both never having learned to drive, both good cooks, and both with a nice sense of humor.
In recent years, Marcia has discovered the internet. Sheís constantly exploring websites and sends us information on all sorts of interesting things. She does more on the computer than I do and thatís saying something. One difference is that I swear at mine and she doesnít.
In any event, Weiís World is dedicated this month to her. Happy Motherís Day, Marcia!
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